=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215401906
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PRINCESS KUKUA AHEDOR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2019
-----------------------------------------------------
Last Update Date | 12/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2100 GEORGE DIETER DR
-----------------------------------------------------
City | EL PASO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79936-3815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-955-2238
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4500 CARTER CREEK PKWY STE 101B
-----------------------------------------------------
City | BRYAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77802-4464
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-532-0010
-----------------------------------------------------
Fax | 979-316-1851
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | AP139886
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | AP139886
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------